Characteristics of frail patients: low body mass index impaired - PowerPoint PPT Presentation

21.09.2017, 13TH EUGMS CONGRESS NICE GOALS OF ANTIHYPERTENSIVE TREATMENT IN THE FRAIL – IS SPRINT APPLICABLE? CONTRA Prof. Dr. Ute Hoffmann Klinik für Allgemeine Innere Medizin und Geriatrie Nephrologie/Angiologie/Diabetologie/Endokrinologie Akutgeriatrie/Geriatr. Rehabilitation/Geriatr. Tagesklinik HOFFMANN UTE: CONTRA

Characteristics of frail patients: • low body mass index • impaired cognition • limited mobility • history of falls • …. Exclusion criteria: High prevalence of frailty in patients • Risk of low adherence with : • Risk, that not all study visits could be completed • diabetes • Risk of orthostatic hypotension • history of stroke • heart failure • CKD • dementia • resident in nursing homes • ..... HOFFMANN UTE: CONTRA

CONTRA 1. SPRINT is not applicable to frail patients, as frail patients were excluded in the study. HOFFMANN UTE: CONTRA

CONTRA Is a lower blood pressure the better in frail patients? HOFFMANN UTE: CONTRA

CONTRA arguments Newer/other studies 2015 Meta-analyses 2016/2017 Studies addressing frail patients excluded in the SPRINT study Post hoc analyses 2016/2017 Subgroup analyses 2016/2017 HOFFMANN UTE: CONTRA

BP targets and BP values: Which BP is “ low “? - systolic BP target in the intensive treatment group: < 120 mm Hg HOFFMANN UTE: CONTRA

n = 302 BPM in office 142/82 mmHg BPM at home 136/77 mmHg 24-h- ABPM 124/76 mmHg Gaborieau V., J Hypertens 2008;26(10):1919-27. HOFFMANN UTE: CONTRA

„ Supervised “ BP measurements in studies: Usually 10-15 mmHg higher than at home or unsupervised in offices Myers MG. J Hypertens 2012, Yannoutsos A et al: Pharmacol Res 2017 HOFFMANN UTE: CONTRA

Drawz PE et al., Hypertension 2017;69:42-50 . Intensive Treatment Standard Treatment < 120 mmHg <140 mmHg n in SPRINT 4678 4683 n office BP vs. 24-h-ABPM 453 444 office BP 119.7 ± 12.8 mmHg 135.4 ± 13.7mmHg daytime 24-h-ABPM 126.5 ± 12.3 mmHg 138.8 ±12.5 mmHg 24-h-ABPM 122.7 ± 11.9 mmHg 133.9 ± 11.8 mmHg HOFFMANN UTE: CONTRA

Drawz PE et al., Hypertension 2017;69:42-50 . Intensive Treatment Standard Treatment < 120 mmHg <140 mmHg n in SPRINT 4678 4683 n office BP vs. 24-h-ABPM 453 444 office BP 119.7 ± 12,8 mmHg 135.4 ± 13,7mmHg Daytime 24-h-ABPM 126.5 ± 12,3 mmHg 138.8 ±12,5 mmHg 24-h-ABPM 122.7 ± 11.9 mmHg 133.9 ± 11.8 mmHg HOFFMANN UTE: CONTRA

CONTRA 1. SPRINT is not applicable to frail patients, as frail patients were excluded in the study. 2. Values < 120 mmHg in SPRINT don‘t correspond to a “real -world “ setting. They correspond even to higher daytime 24-h-ABPM and to higher values in BPM at home or in medical offices. HOFFMANN UTE: CONTRA

patients with diabetes worse CV-outcome better BP lower higher HOFFMANN UTE: CONTRA

patients with diabetes Study BP goals mmHg sys Outcome Side effects Action to Control < 120 vs. < 140 No reduction of Significant higher Cardiovascular Risk cardiovascular rate of SAE in Diabetes Study, events, NEJM 2008 RR of stroke Brunström M et al., < 130 vs. 130-140 No reduction of CV- Significant higher Meta-analysis, MBJ events rate of SAE 2016 HOFFMANN UTE: CONTRA

patients with diabetes 123 studies, 613 815 patients patients with diabetes: BP syst. < 140 mmHg : RR: cardiovascular events BP syst. < 130 mmHg : no RR: cardiovascular events , SAE ↑ HOFFMANN UTE: CONTRA

CONTRA 1. SPRINT is not applicable to frail patients, as frail patients were excluded in the study. 2. Lower values < 120 mmHg in SPRINT correspond even to higher daytime 24-h- ABPM and to higher values in BPM at home or in medical offices 3. Patients with diabetes: < 130 mmHg or < 120 mmHg: No RR in CV events, higher rates of SAE HOFFMANN UTE: CONTRA

Older adults Of all older adults ≥ 75 years with hypertension (U.S.A) … only 64% would have met the inclusion criteria of SPRINT Bress AP et al. Generalizability of SPRINT results to the U.S. adult population. J Am Coll Cardiol 2016;67:463 – 472. HOFFMANN UTE: CONTRA

Hypertension in older adults Study goals: • Mortality ↓ • Macro- and microvascular events ↓ • ….. • Worsening of mental functions Patient goals: • Orthostatic hypotension und dizziness • Elektrolyte abnormalities → functional decline ↓ • Acute renal failure → functional impairment ↓ → mobility ↔ • Too many controls at doctor‘s office HOFFMANN UTE: CONTRA

n = 2629, 79,9 years < 120 mmHg: → No effect on changes in gait speed (4-m walk test) or mobility limitation HOFFMANN UTE: CONTRA

JAMA 2016;315:2673-2682 SPRINT subgroup analysis of the fit ≥ 75 years Intensive BP: syncope 3,0 % vs. 2,4 % n.s. without CKD: Acute renal failure ↑ HOFFMANN UTE: CONTRA

Bress AD, Kramer H, Khatib R et al. HOFFMANN UTE: CONTRA

Bress AD, Kramer H, Khatib R et al. HOFFMANN UTE: CONTRA

HYVET- Studie (HYpertension in the Very Elderly Trial) 159 mmHg 144 mmHg Aus: Beckett NS et al., N Engl J Med 2008;538(18):1887-98. HOFFMANN UTE: CONTRA

Studies in older adults Study n Age Follow- BP sys. References (Mean) up JATOS Study Group, JATOS 4400 73 years 2 years 145 vs 136 mmHg Hypertens Res 2008; 31:2115 – 2127 VALISH 3260 76 years 3 years 142 vs. 137 mmHg Ogihara T et al., Hypertension 2010; 56:196 – 202 , FEVER 3179 69 years 5 years 145 vs. 139 mmHg Zhang Y et al., Eur Heart J 2011;32(12):1500-8 HOFFMANN UTE: CONTRA

Metaanalysis 10857 older patients HOFFMANN UTE: CONTRA

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RR < 140 mm Hg: n.s. reduction of myocardial infarction and stroke HOFFMANN UTE: CONTRA

CONCLUSIONS: CONTRA 1. SPRINT is not applicable to frail patients, as frail patients were excluded in the study. Values < 120 mmHg in SPRINT don‘t correspond to a “real -world “ setting. They correspond 2. even to higher daytime 24-h-ABPM and to higher values in BPM at home or in medical offices. 3. Patients with diabetes: < 130 mm Hg or < 120 mm Hg: No RR in CV events, higher rates of SAE 4. In older adults < 130 mm Hg (sys) should not be recommended. Data about BP targets in frail older patients are lacking. HOFFMANN UTE: CONTRA

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